Rational Healthcare Benefit Design for Self-insured Employers
Most healthcare spending (86%) is for patients with chronic conditions. Twenty percent of the patients generate 80% of the spending. The most effective care for these patients is optimal medical therapy (OMT) delivered by advanced primary care teams. This entire site is about that approach. These teams improve health and save money by reducing hospitalizations, lengths of stay, and specialty referrals. I have done this work myself. Despite these proven benefits, one quarter of Americans don’t have a primary care doctor at all. We have identified some companies where only 30% of the workforce have a primary care doctor. Very few Americans receive their care through advanced primary care teams producing OMT.
That is a shame, because there is hard evidence that optimal medical therapy improves health and saves money in patients with heart disease and related conditions like high blood pressure, diabetes, heart failure, and chronic kidney disease. That is the care that every one of your employees with these conditions should be receiving. Your employees who have had a heart attack and are on OMT are ten times as likely to be alive in five years compared with those receiving usual care, the care that most of us receive. If they have type 2 diabetes and chronic kidney disease, those on OMT have one fourth as many heart attacks, one fifth as many strokes and one sixth as many go on dialysis compared with those in usual care. They live 8 years longer free of heart attacks and strokes. They are one third as likely to be admitted to the hospital for congestive heart failure.
Advanced primary care teams delivering OMT can make this difference for you. You should promote developing them in your area and you should change your benefit design to promote their use. Your lowest paid employees, especially those who are black, Hispanic, or Native American, carry the highest burden of these chronic diseases and suffer the most complications. If your health plan has platinum, gold, silver, and bronze levels, these patients are usually going to pick the bronze level because that is all they can afford. The bronze level has the highest copay and deductibles for primary care visits and that is a barrier that you want to remove. You will save money all day long by having no copay for a visit to an advanced primary care team and no copay for generic medications to treat heart disease, diabetes, high blood pressure, high cholesterol, and other chronic diseases.
If you don’t remove these barriers and patients don’t receive OMT from primary care for these conditions, they will develop more expensive complications. These complications will require using specialists, emergency rooms, and hospital admissions. They will meet their deductions and cost you much more money. You will have more absenteeism and perhaps lose the employee to death or disability. Promoting advanced primary care teams that deliver OMT consistently is acting in your best interest
One of our advanced primary care team clients in a rural community setting has cut healthcare costs in half while reducing hospitalizations by 80% and emergency room visits by two thirds. We have helped them show their self-insured employer how effective they are with hard data that proves this performance. Their employer can see this data on their dashboard at any time. They continue to get better and improve their processes. We can help you do what they do!